Introduction and abroad with an estimated 17.7 million



Heart failure and associated cardiovascular diseases are
undeniably some of the most serious conditions currently faced by the population
in Ireland and abroad with an estimated 17.7 million deaths worldwide, and 80%
of those being due to heart attacks and stroke1 (World Health
Organisation, 2017). According to the HSE2 around 90,000
people in Ireland suffer from some form of heart failure with most patients
being in their 70s. Not only is heart failure one of Irelands greatest causes
of death but it is also the cause of 20,000 admissions to Irish hospitals each
year (Health
Service Executive , 2017). The prevalence of heart failure is
also set to rapidly increase due to an aging and ever-expanding population
although currently there are over 10,000 new cases each year3 (Irish Heart
Foundation , 2017).

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Not only does the syndrome have a direct and severe impact
on the lives of those people who suffer from it but its rampant effects also
extend into the economic environment in Ireland. The pathophysiology of this
condition is characterised by numerous traits such as high morbidity, high
mortality, frequent readmission to hospitals, and a great reliance on informal
care which in turn creates a great burden for not only the Irish but also the
global economy7 (KennellyB., 2014). According to a 2015 study carried out by The
Heartbeat Trust, the annual cost of Heart failure is around €660 million with
€158 million being attributed to direct costs with primary care related
expenditure accounting for 25% of this figure and drug costs accounting for a
further 16%8 (The Heartbeat Trust, 2015).

Heart failure can be described as a complex clinical
syndrome in which the heart fails to pump blood around the body at a sufficient
rate to meet the body’s metabolic demands. Symptoms of heart failure include dyspnoea,
fatigue and weakness, and oedema in the legs2 (H.Lund L, 2017) (Health
Service Executive , 2017)6. Depending on ejection fraction,
natriuretic peptide levels, and presence of structural heart disease and
diastolic dysfunction, heart failure can be split into three subtypes. These
are heart failure with reduced ejection fraction (HFrEF), heart failure with
preserved ejection fraction (HFpEF), and heart failure with mid-range ejection
fraction (HFmrEF)6 (H.Lund L, 2017). Due to the broad aetiology of heart
failure, there are numerous treatments available in its management. Most commonly
used drugs prescribed for those patients suffering from heart failure include
diuretics such furosemide to increase salt and water excretion, angiotensin converting
enzyme inhibitors such as enalapril which reduce vascular resistance, Beta
blockers such as bisprolol, and aldosterone antagonists such as losartan (Health
Service Executive , 2017) (Rang H P)

There are of course alternative treatments to heart failure which do not
limit themselves to pharmacotherapy, the most important of which are lifstyle
changes. These include smoking cessation, healthy eating, relaxation, and
emotional support. All of these would have a profound reduction on the likelihood
that another heart attack would occur as well as improvving the patient’s
condition. In more serious cases surgica procedures such as implementation of a
pacemaker, which monitors and corrects heart rate, or an implantable
cardioverter defibrillator, a device which detects atrial fibrillation and
shocks the heart electrically in order to correct it. The heart may also be
maintained through the use of surgery. If a valve is faulty, it may be replaced
with an artificial one or repaired through a surgical procedure. Other surgical
approaches include revascularisation which incloves a coronary angioplasty or a
coronary artery bypass graft which would allow blood to flow into the coronary
arteries with greater ease. The final and most drastic solution for heart
failure patients in which medicines or other surgical methods did not help is a
heart trnsplant. It involves the replacement of the diseased heart with a
healthy one. This procedure carries great risk as well as there being a
shortage of hearts for transplant (Health Service Executive , 2017).

Due to its multiple levels of severity, heart failure is
classed according to this severity. The type of therapy and the drugs provided
to the patient will depend on the class of heart failure assigned to them. The
classes range from I to IV with I being asymptomatic and IV being very severe. Treatment
with ACE inhibitors has become standard for all classes but treatment still
varies from patient to patient to the complex nature and aetiology of heart
failure. For example, in Class I, ACE inhibitors are usually used as a
monotherapy where systolic dysfunction and an ejection fraction of below 45% is
observed but these patients may also be suffering from atrial fibrillation in
which case they are given digoxin and warfarin in order to prevent a stroke
caused by an embolism from the atria. Amiodarone is given to patients who
experience ventricular or supraventricular arrhythmia. Treatment regimen ad
dosage must be tailor made for each patient due the varying contributing
factors of heart failure and its broad spectrum of severity. As the severity escalates,
the number of different drugs prescribed and the dosages are also changed and
increased (Greene R.J).

Due to the condition’s severity and great number of patients
suffering from it, it is imperative for pharmacists as primary care providers
to actively contribute in the management and care of such patients. Heart
failure is a condition which can be treated through the usage of
pharmacological agents as well as lifestyle changes, and surgery allowing the
patient to live their life normally2 (Health Service Executive , 2017) . There
has been evidence brought up that a multidisciplinary approach to patient
management provides an improvement to the patient’s clinical condition with pharmacists
being vital members of this team4 (W.M. Cheng J, 2014). Studies such as the one
conducted by A. Warden et al5 (WARDEN, 2013) showed significant reductions in
the rate of readmission of heart failure patients with an increase in patient
satisfaction when a pharmacy managed program was in place for provision of
education and discharge instructions for these patients.





When describing the role of pharmacists in the care of
patients with heart failure, the immediate thought of outpatient care in
clinical and community settings springs to mind but the pharmacist’s roles
start in fact before the patient is discharged from the hospital. One such role
involves patient medication reconcilliation and education.  As heart failure mainly effects patients of
the elderly population, the risk of drug related harm is increases along with
the risk of unwanted effects therefore somewhat complicating the care and
pharmacotherapy of these patients (Christensen M, 2016). Certain studies have already
been carried out which conclude that pharmacists’ roles in medication
intervention for these patients can have a great impact on reducing the
probability of these errors and further improving care for patients with heart
failure (W.M. Cheng J, 2014). One such stuy carried out by Walker P C et al in
2009 showed that pharmacist intervention did in fact reduce the number of
medication discrepencies in patients but unfortunately did not have any major
effect on readmission rates. During the study a pharmacist was assigned to an
intervention group where they actively participated in counselling, educating, assesed
appropriatness of discharge medication, and conducted postdischarge phone calls
with the patients amongst other important roles. The study showed a 20% drop in
discrepencies in the intervention group but did not totally eliminate it
unfortunately  (Walker P C, 2009).  

There are other potential roles of the pharmacist in predischarge patient
medication through medication initiation, dosage titration, adjustment, and
monitoring. There are numerous drugs available for the treatment of heart
failure, most notably angiotensin converting enzyme inhibitors, beta blockers,
and angiotensin receptor blockers (used in patients who happen to be intolerant
of ACE inhibitors.) (Health Service Executive , 2017). These drugs are
generally recommended for first line treatement of heart failure. According to
a study done by Pitt B et al, the drug spironolactone was found to also be
rather efficacious in the treatment of patients with heart failure as the drug
caused a 30% drop in mortality as well as a reduction in apparent symptoms (Pitt
B, 1999). Despite the usefulness of these drugs, they are rather
underprescribed in patients with heart failure espeially in older patients. Not
only are they underprescribed but it was also found that the dosages were lower
in older patients  (Michel K, 2008). As
seen in multiple studies, and protocol driven heart failure clinics driven and
monitored by nurse and pharmacist specialists can positively influence the drug
therapy of patients. It has been shown that through effective prescription and
uptitration of medication doses, the prognosis of heart failure patients can be
improved along with a reduction in systolic blood pressure and and heart rate
with minimal deterioration in renal function or incidence of hyperkalaemia (Jain
A, 2005).

Once patients are discharged from the hospitals, it is the responsibility of
the medical practitioner that the patient is able to take care of themselves
and maintains a smooth transition of hospital to home. Readmission rates for
heart failure are one of the highest at 24 – 44% and are set to rise by more
than 50% in the next 25 years (The Heartbeat Trust, 2015). A large proportion of the 660 million euro cost
of caring for heart failure patients is incurred through these recurrent
readmissions to hospital. These readmission rates have become invaluable as an
indicator in the measurement of  quality
of care in hospitals or the efficacy of certain primary care models. A major
problem for heart failure patients is poor transition of care which is responsible
for adverse effects and reduced patient satisfaction (Arora VM, 2010). A study carried out by Donaho et al (Donaho EK, 2015) found that when a multidisciplinary
allied health clinic including a nurse and a pharmacist were tasked with
providing protocol driven post discharge evaluation and management, 30 day all
cause readmissions did in fact drop by 44.3% in comparison to the regular  30 day all cause readmission rate at this
hospital. The protocol used involved a planned follow up within 1 week and
between 4-6 weeks post discharge. The follow ups included physical examinations, medication education and reconciliations,
medication up?titration per protocol, individualized HF
disease education emphasizing symptom recognition and reporting, coordination
of outpatient health care resources, and a comprehensive discharge plan.
Another study made by Warden BA et al (WARDEN,
2013) further proved that the involvement of
pharmacists in medication education and discharge instruction had a very
positive impact on outpatient medication adherence and readmissions, mortality,
and length of hospital stay. The study also showed a significant relative risk
reduction of 55 to 69% which can be attributed to more than just the use of
proper drug therapies but also enhanced patient understanding of and
improved adherence to proven medications, rec-cognition and proper management
of exacerbation symptoms, and a strong emphasis on and frequent reminders for

Pharmacists have the potential to play a vital role not only in the drug
therapy of heart failure patients but also in their education. Varma et al (Varma S,
1999) conducted a study evaluating a structured pharmaceutical approach in the
provision of education from a pharmacist on the disease state as well as
medication and management of the heart failure symptoms. The patients had also receive
information booklets on the discussed topics. The patients were assesed on
certain criteria at baseline and 3,6,9 and 12 months after. The patients receiving
the education exhibited a much greater drug compliance to the drug group
resulting in lower readmission rates as well as improved physical capabilities
and exercise capacities. Those patients who received the intervention also had
extensive knowledge of their drug therapy.

direct intervention with patients does bare rather promising results, a
multidisciplinary approach can be just as if not more succesful. This can be
seen in the article written by George et al (George J, 2011) which describes
the community pharmacists role. The article found that community pharmacists
play a vital role in the screening of patients for cardiovascular disorders
e.g. heart failure. The pharmacists would be responsible for detecting the
early signs of these disorders in some harder to reach demographics increasing
the detection rates and allowing these patients to receive necessary treatment
as soon as possible. The pharmacists in this case can be seen to collaborate
with medical practioners sa once the disease was detected, the patient was
referred to the general practitioner in order to receive a more in depth
analysis and evaluation of their condition. This shows how a collaborative care
process can improve the efficacy and outcome of treatment in heart failure
patients. This can be further seen in reviews such as the one published by
Omboni et al (Omboni S, 2018) which shows multiple studies done showing that
pharmacist intervention through multidisciplinary care efforts has a rather
positive outcome on hospital readmissions, quality of life, patient wellbeing,
and length of hospital stay. These interventions generally consist of
medication reconcilliation, patient education, and collabarative medication

potential role for pharmacists in the future may include management and
maintenance of a ventricular assist device. According to Givertz MM (Givertz,
2011) there are currently a great range of devices being developed for pateints
with advanced heart failure. These devices reange from fully artificial hearts
to ventricular assist devices. These devices have recently been approved for
the use of lifetime support for patients suffering from end stage heart failure
though before they were exclusively used temporarily as a bridge to heart
recovery or heart transplant. VADs assist the heart in its function and can
improve the quality of life for many patients. A study by Jennnings et al (Jennings
DL, 2011) found that pharmacists could contribute to the maintenance of these
mechanical devices through the provision of antimicrobial agents. The study
showed how pharmacists assisted the patients with dose, frequency or route of
administration, ordering lab tests or discontinuing the therapy. It is believed
that as this medical field expands and develops, pharmacists will have more of
a prominent role in the use and management of these mechanical devices in
patients with end stage heart failure.





Elucidating from the information acquired from the aforementioned
studies, articles, and sources of information, it can be confidently said that
pharmacists have a great many vital roles in the care of patients with heart
failure. It can be seen that as active participants in the care of these
patients, they have a significant positive impact on a number of therapeutic
outcomes including decreased hospitalisations and readmissions to hospital, and
an improved sense of wellbeing amongst the patients accompanied by a much
greater improvement in the quality of life.  Pharmacist roles in management and care of
heart failure patients is categorised into three main areas which are the most
documented in literature. These are medication reconciliation, patient
education, and collaborative medication management.